HomeMy WebLinkAboutRECYCLED PROPERTIES Recylcled Properties SubdivisionOnsite File
Recycled Properties
Subdivision
Formerly Poggas Lts
4, 5, 6, E2 7, 8 and
9
lorage
it Department
vt1° Program
0 - http://Www,muni.org/onsite # (907) 343-7904
Dning Log
Subdivision Sl�
Sis
Block .. , ,� �=
LOn-site
R Section Lot
Water Wastewater Program certified contractor performing the veil decommissioning:
ignatt#
g A,
Well decommissioning date Method of decommissioning: AMC 15.55.06OLI a. b. � .
Location: Use the space below to provide a drawing of the proles showing the following item,
North arrow
Decommissioned a{ell,
Other water wells on the property,
Two separates tag-fie;distanc for each well shown on the drawing,
Note: The sing -tie distances shall be measured from either germane t structures or the property corners, t
01
4
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:&dor-srrsaanity e►opr entiCieveioprnert ervicest �ssldsng mix, site " ater and Vastew terTorrrCrierfiarms' tl Decrsmmisibning form.doc
REQUEST
FO APP~
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
Name .of person requesting approval
2, ~a~ of property~owner
h~ g.~l description .....
4. Number<of ))edrooms in house
5, Water Analysls:
a. Bactemial
b. Detergent.,,
Well data:
Depth, '
c. Casing Size ~ ~!
dj
Distance from well to closest existing or proposed:
1, $~wer line
2, Septic tank,,/~-
3, Seepage Area,.,,¢~>!
Cesspool'
5, Property Line
Other sources of possible contamination, i.e., creeks, lakes,
houses~ barn~ drainage ditch~ etc.
Sewage disposal system,
a. Age of system ~1~a~.~,S
b. Septic tank capacity in gallons ......
1. If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepage pit size and type
Distance to property line to house foamdation .~
Percolatio~ Text '~esult$
f. Percolation Test performed by
Use the reverse ,side of this form to show diagram. Diagram should include
· ~-the roi%owing information: p~operty lines~.well location, house location~
~ptic tank location, disposal area location, location of percolation test,
ar,~ direction of ground slope.
The 1 ' on this form ~s true and correct to,the best of my knowledge.
' l'
' ~?~c~, ~ .~-~,~. :/,¢.7.
S~gfi~,~ure of Applicant Date Si~ned
TO BE FILLED OUT BY HEALTH DEPA.P.,T~ENT PERSONNEL
~e above described sanitary facilities are hereby approved, subject to the
.......... ~6'llowing conditions: "'
Conditions:
The above described sanitary facilities are disapproved for the following
Sig~atu of ~:ef&~12 ;'-'~',.'~
~o~ ~ ' '' '
App' 1 is valid for one year following the date of approval.
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